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Stop the day of surgery scramble

Publish Date: 6/5/2013

By standardizing preadmission forms and processes and holding firm to enforcing and reinforcing the new approach, Franciscan Health System in Washington has managed to reduce the detective work around surgical preadmission.

This big step to implement one standardized preadmission approach was initiated by a preadmission redesign team of hospital staff, physicians, and scheduling staff from various physician offices. They conducted a Lean value stream mapping workshop to eliminate the “right” waste, identify leading indicators, and set the “hard stops” necessary for effective and sustainable improvement, according to team leader Tammy Dobson, BS, CPM, CSSBB, an internal project management and process improvement specialist for Franciscan Health System.

“Evaluating this value stream allowed us to visualize the breakdown between patient flow and information flow,” Dobson explains. The team identified 34 gaps in practice.

“We were all over the map with different preadmission processes for each of our six sites, plus different forms and processes from physician’s offices,” notes Renae Battié, MN, RN, CNOR, associate vice president for Franciscan Health System perioperative services and AORN vice president. “We had lots of good people with good intentions but no requirements.”

Here are the key elements the team tackled to standardize preadmission and stop the day of surgery scramble:

1. Standardize the surgical scheduling formThe existing form was revised for consistency, and disseminated to all physician offices for required use. The form was also shaped to be set up within a new system-wide electronic medical record (EMR) slated for go-live later this year.

2. Implement a preoperative risk formWorking closely with anesthesia providers, the team shaped a simple form to be filled out by the physician’s office and/or the patient to determine high-risk patients who need to be seen in person for preadmission screening. This gave direction to the offices for why a patient appropriately could be screened by telephone, which previously was not used as much.

3. Require H&P prior to preadmission screeningPreviously there was no requirement for what documentation needed to be in front of the preadmission nurse prior to screening in person or by phone. By requiring the H&P, or alternate paperwork with similar information, preadmission screening is more thorough, supports background for medical diagnostic testing and supports the nurse in asking the patient the most appropriate questions.

4. Require completed chart two days prior to date of surgeryA system-wide rule requires surgeries be cancelled if the patient’s preadmission chart is not complete two days prior to surgery. This decision was made with senior leadership and perioperative physician leadership support. Each site director has the discretion to make this cancellation.

It’s been a challenge to enforce this surgery cancellation rule, as there have been many issues with dictation systems and physician office workflows. However, the improvements have continued and the upcoming EMR will support the new processes. The team has also become more flexible about accepting alternate forms of the H&P prior to preadmission screening.

Battié says having Dobson as a dedicated project manager assigned to the project was key to successful implementation because she has the ability to focus on the communication and sustainment aspects of the project.

“Building and refining clear channels of communication with the physician offices and among hospital staff has been critical to supporting this standardized process,” Battié stresses. “Standardized workflows are great, but they won’t last if you don’t have the ongoing education, communication channels and consistent follow-up to keep them functioning.”

Additional Resources:

Register for an eCongress presentation to find the business analysis, implementation timeline and other details from this preadmission redesign.Scroll to the presentation titled “Redesigning the Pre-Admission Process for Impact.”